Sec. 10.09.69.04. Participant Enrollment and Disenrollment

A. Anyone may refer an individual into the REM program including, but not limited to a:

(1) Family member;

(2) Physician;

(3) Discharge planner;

(4) Hospital;

(5) Clinic;

(6) Social worker; and

(7) Managed care organization (MCO).

B. The Department shall enroll an individual determined eligible in the REM program when:

(1) All pertinent documentation regarding needed medical services is received, reviewed, and approved;

(2) Confirmation of the individual's election to participate in the program is received; and

(3) The individual is being discharged from an institution or transitioning from an MCO and service coordination is complete.

C. When an MCO participant is referred to the REM program for enrollment, the MCO shall:

(1) Provide confirmation of the qualifying diagnosis to the Department; and

(2) Continue to provide the MCO participant's care until the Department confirms the diagnosis and enrolls the MCO participant into REM.

D. An individual shall be enrolled in or auto-assigned into an MCO as specified in COMAR 10.67.02, not later than 60 days from the date the individual becomes ineligible for REM, as a result of changes in the diagnosis or age group criteria specified in Regulation .17 of this chapter, except when the individual was allowed to remain in REM in accordance with §I of this regulation.

E. A REM participant may elect to disenroll from REM and enroll in an MCO by notifying the Department of that decision except when the individual was allowed to remain in REM in accordance with §I of this regulation.

F. Election to Remain in MCO.

(1) An individual who becomes eligible for REM while enrolled in an MCO may elect to remain in an MCO by notifying the Department of that decision.

(2) When a REM-eligible individual elects to remain in an MCO, the Department, in consultation with the MCO and the REM-eligible individual, may determine whether the MCO can appropriately meet the individual's medical needs within the parameters of the program benefit package as described in COMAR 10.67.06.

(3) If the MCO determines it cannot appropriately meet the individual's medical needs, the MCO shall submit to the Department written justification for its decision.

(4) If the Department determines the MCO can meet the individual's medical needs, the Department shall notify the MCO of its decision in writing.

(5) If the Department determines that the MCO cannot appropriately meet the individual’s needs, the Department shall issue a written determination to the individual and the MCO which includes:

(a) The reason for the determination; and

(b) An explanation of the individual’s right to appeal the determination according to the procedures set forth in COMAR 10.01.04.

(6) If the Department determines that the MCO can appropriately meet the individual's medical needs, the individual's election becomes effective and cannot be revoked without cause for a period of 1 year from the effective date.

G. The Department shall allow an individual who, immediately before enrollment in REM, was receiving medical services from a specialty clinic or other setting to continue to receive services in that setting on enrollment in the REM program when the provider is willing to participate as a Medical Assistance fee-for-service provider.

H. An individual eligible for REM who has elected to enroll in an MCO or to remain enrolled in an MCO may not receive REM services under the REM program.

I. The Department shall disenroll from the REM program a participant who no longer meets the conditions specified in Regulation .03 of this chapter unless:

(1) The participant does not meet the condition under Regulation .03A(1) of this chapter because the participant becomes eligible for Medicare; and

(2) At the time the participant became eligible for Medicare the participant was approved for and was receiving private duty nursing, CNA, CNA-CMT, HHA, or HHA-CMT services under the REM program.

J. An individual disenrolled from REM by the Department who maintains HealthChoice eligibility is subject to the MCO enrollment provisions specified in COMAR 10.67.02 except when the individual was allowed to remain in REM in accordance with §I of this regulation.